Klamath Family Head StartVolunteer Application Name First Middle Last Address Street Address City State / Province / Region ZIP / Postal Code PhoneDate MM slash DD slash YYYY How did you hear about us? Counselor Friend Employment Agency Relative Other Check any of the following which you curently hold: Negative TB clearance with in 1 year First Aid Card CPR Card Food Handler's Card CDL Criminal History Registry Other State your reasons for interest in volunteering with Head Start:List special skills you possess (office, clerical, teaching, mechanical, etc.) which could be used at Head Start:List languages which you speak proficiently: List languages which you write proficiently: List languages which you read proficiently: Give a schedule of when (days, times) and for how long you are available to volunteer:In what kind of job(s) would you be interested? (Be specific.)History of work / volunteer experience List all previous experience with responsibilities similar to those you might have at Head Start.From Mo/Yr MM slash DD slash YYYY To Mo/Yr MM slash DD slash YYYY Place/Address/Phone Job Title Duties From Mo/Yr MM slash DD slash YYYY To Mo/Yr MM slash DD slash YYYY Place/Address/Phone Job Title Duties From Mo/Yr MM slash DD slash YYYY To Mo/Yr MM slash DD slash YYYY Place/Address/Phone Job Title Duties From Mo/Yr MM slash DD slash YYYY To Mo/Yr MM slash DD slash YYYY Place/Address/Phone Job Title Duties From Mo/Yr MM slash DD slash YYYY To Mo/Yr MM slash DD slash YYYY Place/Address/Phone Job Title Duties References List name, address, and telephone number of three people who are not related to you and are not previous employers:1.2.3.I hereby state that the information given by me in this application is true in all respects. I authorize any former supervisors to release information pertaining to my work record and job performance. I authorize the individuals listed as references to release any information that any pertain to my potential placement. SignatureDate MM slash DD slash YYYY NOTE: After review of this application and presentation of Criminal History Registry, you will be contacted for a brief placement interview.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
